Table 2 Summary of Focus group key findings- Barriers and enablers to goal-setting in Queensland Rehabilitation Services

Teamworking

Knowledge

Lack of understanding of a client centred goal-setting focus (.^b)

“How do we separate out the individual discipline goals? For example, you know, be able to pronounce this, or be able to match words to pictures with 50 per cent accuracy … How do we distinguish from that from the shared goals?” (Site 3)

Skills

Skills to set rehabilitation goals with clients outside of discipline skill sets (.^b)

“I could set a broad goal, but it probably wouldn’t be… I wouldn’t have enough insight to have a SMART goal for that.” (Site 3)

Social and professional role and identity

Absence of the nursing role (inpatient rehabilitation) (.^b)

“we don’t get included…in the MDT, or the allied health goal-setting,” (Site 1)

Environmental Context

The need for consistent processes (^a) but the want for flexibility (.^b)

“I think the challenge is always trying to find one process, and one tool that everyone is going to use… but if we really want to be person-centred, then we need to be flexible about how we do our goal-setting” (Site 4)

The case conference forum (.^a)

“case conference is a good opportunity where we come together and feedback to each other about what goals we’ve been working at, and then formulate a sort of more shared goal” (Site 1)

Electronic and paper-based record keeping systems

“I spend more time doing paperwork than I actually do client work” (Site 5)

“then every outcome measure is…put into a database and there’s a lot of crosschecking” (Site 5)

Beliefs about consequences

Lack of client involvement in case conference (.^b)

“it’s fragmented though, through EMR [electronic medical record]…plus each therapist will write up what their goals are, so there’s no actual framework where they’re all in one” (Site 3)

“we probably don’t—in this service—have a platform where we all get together as an MDT with the patient and actually look at their goals and how they’re progressing” (Site 3)

Shared decision-making

Knowledge

Skills

Clinicians skills to facilitate goal-setting interactions (^a/.^b)

“potentially for junior staff, they’re so overwhelmed… learning their discipline specific stuff, that to think broader can be quite hard” (Site 1)

“I think, a big challenge for our team in particular, is that level of skill and experience with doing that very specific goal-setting and being able to break it down with the patient engaged in that process and show them how it all connects, and coming up with very specific goals that are still their goals” (Site 2)

Beliefs about consequences

Timing of goal-setting interactions (possibly too early inpatient rehabilitation) (.^b)

“We’re still grappling with, okay, this is what they’ve done in a few days since their stroke, we think this is what they might get to based on their type of stroke and experience …So if we’re grappling with it and we’re expecting them to have some kind of concept, it’s really hard to—to do it so early” (Site 3)

Beliefs about capabilities

Clinician challenges with those who have cognitive impairment or who are not ready to goal set (.^b)

“their cognition means that they are … insightless to their impairments and function so it ends up being therapist directed” (Site 1)

Environmental context and resources

Time taken to conduct goal-setting interactions (^b) Service setting context (.^a)

“the amount of time it takes to do goal-setting well, which, here [community rehabilitation] … it’s a bit better because you can actually say, “Okay, I need to actually make an appointment time to do this. Whereas in inpatients, you’re lucky if you get two minutes to spend on goal-setting, realistically” (Site 4)

Using measurement tools and questionnaires (.^a)

“others who maybe are having a bit more trouble really getting out clear goals, or coming up with goals, then I might switch to a tool like the COPM or something, to help.” (Site 4)

Meaningful and specific goals

Social influences

Clinicians obligation to set goals relevant to the role of the service (.^b)

“Or goals that are appropriate to our service, is harder to extract than just personal goals” (Site 2)

“I think there can be some conflict between the patient’s own goals that are maybe set spontaneously without much guidance from therapists, and then from the service perspective” (Site 2)

Beliefs about consequences

Clinicians beliefs that goal-setting needed to be realistic to avoid client disappointment (.^b)

“cause otherwise you’re setting them up to fail” (Site 1)

“it’s that fine line between them being something that the patient wants and something that we think is achievable” (Site 1)

Environmental context and resources

The differences in goal focus between inpatient and community rehabilitation settings (.^b)

“person centred goal-setting is this big board idealistic thing that sometimes we maybe struggle to achieve in the setting, because the setting dictates what you work on” (Site 1)

Action planning and review

Knowledge

Understanding the differences between goals and actions or staff task lists (.^b)

“normalising their calcium, normalising their potassium, normalising whatever. Getting them pain-free. Getting on top of their pain is a goal” (Site 3)

“we’ve got a whole pile of participation goals, activity goals, impairment goals and there’s some education goals or information, like information about EPOA [enduring power of attorney] and wills we pop … that can be a goal as well” (Site 5)

Memory attention and decision-making

Goal review and feedback was often ‘forgotten’ (.^b)

“people are generally quite good at going and getting the initial goals off people, but the review process of reviewing the goals and things, I don’t think happens consistently” (Site 2)

Environmental context and resources

Using charts to track progress and communicate goal actions (.^a)

“we will have their goals up on the wall and we will tick them off and its, it’s exciting for nurses and patients to see…. or well anyone who helps that patient… to see that it’s been ticked off, is a big achievement on everyone's behalf” however staff identified this was a “more reactive than proactive” approach (Site 1)